Professional Documents
Culture Documents
Best Health Outcomes For Maori
Best Health Outcomes For Maori
Best Health Outcomes For Maori
Best health
outcomes for
Maori: Practice
implications
Acknowledgements
Best Health Outcomes of Mori: Practice Implications
This resource booklet has been prepared by Muri Ora Associates for the Medical Council of New Zealand.
The Council would like to formally acknowledge the contribution of Prof Mason Durie, Dr Paratene Ngata,
Dr James Te Whare all of whom reviewed the draft material, and the Muri Ora Associates team. To the many
other people who have contributed to this booklet, thank you.
Please check for updates to this document after December 2008.
Contents
INTRODUCTION
03
BACKGROUND EVIDENCE
04
04
06
Mori health
06
Health inequalities
07
08
09
10
11
14
14
15
16
17
i.
17
ii.
Family/whnau support
19
19
20
v.
21
Physical contact
21
22
22
23
x.
Special issues
23
1. Surgery
23
2. Anaesthesia
24
xi.
3. Mental health
24
4. Pain
25
5. Hospitals
25
6. Mate Mori
25
26
xii. Autopsies
28
CASE STUDIES
30
SUMMARY
39
40
42
Introduction
*See Ministry of Health Implementing the New Zealand Health Strategy (Ministry of Health 2003), for
further information on Acknowledging the Special Relationship between Mori and the Crown under the
Treaty of Waitangi.
Background evidence
Mori health
Mori make up 14.7 percent of the New Zealand population
(as at 2001), with every local authority area in the nation
having a Mori population of at least 4.5 percent,6 yet
Mori have the poorest health of any New Zealand group.
This places enormous costs on society both in terms of
avoidable human suffering and financial expenses of lost
work days and increased healthcare expenditures.
Health inequalities
Mori have less access to medical care and rehabilitation
services, and lower injury claim rates when compared
with non-Mori.19-23 Even though Mori turn up for GP
appointments at the same rate as non-Mori, they obtain
fewer diagnostic tests, less effective treatment plans,21,24
and are referred for secondary or tertiary procedures at
significantly lower rates than non-Mori patients.25
Differential approaches
to treatment
Cultural competence
and clinical competence
The impact of
culture onhealth
Principles of
culturally competent
care for Maori
Mori views on health take a holistic approach and embrace
four cornerstones of health:50
Because Mori are often less likely than other patients to ask
questions or challenge a doctor whom they perceive to be
acting inappropriately, it is particularly important to present
yourself as open to questions, and to solicit feedback from
the patient and/or whnau regularly.
Family/whnau support
Community and whnau support are a key part of Mori
health. As mentioned above, the individual is defined in
terms of their relationship to the whnau, and the whnau
in turn has a responsibility to take care of its individual
members. For this reason, it is very important that the
medical team recognise that a Mori patient may wish for
whnau members to be involved in all aspects of their care
and decision making. This may take the form of nominating
a person to speak on their behalf and/or the behalf of the
whnau, consulting on all decisions, bringing food for the
patient, staying with the patient (including overnight), and
attending surgical procedures. It is particularly important
that visits by whnau members are permitted when a
patients death is expected and/or imminent.50 (See also
Death and Dying below.)
Examining patients
While it is common courtesy in many cultures to ask
permission before touching or examining a person, it is
particularly important to do so with Mori. You will, of
course, have introduced yourself to the patient and any
whnau members present before this point, but you
should, prior to beginning any physical examination, explain
briefly what you will do, why you are doing it, and request
permission to proceed. Be aware that, depending upon
the examination, some whnau members may choose to
remain with the patient. You should ask the patient and
whnau what their preferences are, rather than automatically
asking family members to leave the room while you make
yourexamination.
You may notice that a Mori patient wears taonga (valuables/
heirlooms). If this is the case, only remove them if their
presence poses a safety hazard. Taping them in place is
generally considered preferable to removal. If they do pose
Physical contact
In Mori culture, the head is the most sacred (tapu) part
of the body. For this reason, you must be careful to ask
consent before touching the head, and avoid touching
it casually. As part of the tapu/noa separation, it is also
important that anything that comes into contact with the
body (or bodily substances) should be kept separate from
food (or items associated with food, such as dishes or tea
towels). Because food is considered noa, you should never
pass food (such as a meal tray) over a persons head, which
is tapu. Doing so could be considered to strip the person
of all personal tapu. Different linens can be used to ensure
that items that touch the head are not mixed with those that
touch the rest of the body.50 For example, most non-Mori
patients will be comfortable moving a pillow from beneath
their head to under their leg (or vice versa), but Mori may
view this as a violation of tapu. For this reason, pillowcases
should be different colours, so that those used for the head
can be differentiated from those used for other parts of the
body.50 Similarly, different flannels should be used to wash
the head and the rest of the body.
Towels used on the body should never be used for food,
and freezers used for food (or medication) should not be
used for any other purpose.50
Body language
Body language can be different between Mori and
non-Mori. For example, although Mori have a preference
for face-to-face communications so that each party can
look upon the face of the other, this is not a request for
direct eye contact. Also be aware that you do not need to
prolong eye contact Mori often say that we listen with
our ears, not our eyes.
This is because for many Mori, looking your conversation
partner in the eye sends a signal of conflict or opposition.
Furthermore, if there are more than two participants,
sustained eye contact can exclude the ones not actually
speaking.15 By contrast, the Mori will look at a neutral spot
and thus be better able to focus on what the speaker is
saying and how he is saying it, rather than being influenced
by his appearance.15
Sustained eye contact can also be interpreted as a sign of
disrespect, especially when this involves gazing at authority
figures such as doctors and nurses in a medical practice or
hospital. It may be better to avoid prolonged eye contact with
Mori patients as that may make them uncomfortable, or feel
like they are being scrutinised or criticised orchallenged.
Keep in mind that although lack of eye contact could be
a sign of respect, it could also be due to anxiety, anger,
boredom, inattention, or fear, just as with any other patient.
You will need to draw upon other signals from the patient (or
their whnau) to decide which is the correct interpretation. If
you are unsure about this or any other non-verbal signal, ask.
Traditional medicine/Rongoa
Some, especially older, Mori may consult a tohunga before,
after, or instead of, seeing a doctor.15 The tohunga is often an
older relative who looks after the well-being of the whnau and
will be very knowledgeable in human nature and psychology,
as well as having great expertise in tapu and noa laws.15
Dr Elder writes:
Special issues
1. Surgery
In general, Mori dislike body mutilation, and this can
affect how people regard the removal of diseased body
parts. For this reason, it is important that you give a
very clear explanation regarding surgical procedures,
including what will be done and why. In particular, when
body parts or tissue will be removed and/or examined,
be sure that Mori patients are consulted about the final
disposal of that material.50
3. Mental health
Mental illness remains a serious health issue for Mori,
and the rate of psychotic illness among Mori has
been said to indicate a culture under siege.57 First
admissions to psychiatric institutions are higher for
Mori than Pkeh, with roughly 20 percent of all Mori
admissions related to drugs and alcohol.53 In addition,
more Mori are committed to hospital involuntarily,
under the Mental Health Assessment and Treatment
Act, which increases the likelihood that the patients will
consider the hospitalisation experience as punitive rather
thantherapeutic.53
The increase in diagnosed mental illness among Mori
holds for both genders. Mori women are at higher risk
of alcohol and drug abuse and of being admitted to a
psychiatric facility than non-Mori women, while Mori
men are more likely to be treated in a forensic care
setting, to be diagnosed with schizophrenia, and to
spend less than half the time in hospital for this
diagnosis than non-Mori.53
The psychiatric readmission rate for Mori is twice
that of European New Zealanders, and Mori are
diagnosed with schizophrenia at higher rates than
Pkeh.53 Worryingly, this may not reflect the true
rate of schizophrenia among Mori, as many of these
patients recovered rapidly and did not follow the
longer-term course of schizophrenia.53 This suggests
that lack of understanding about these Mori patients,
Autopsies
As with all groups, Mori expect a complete and accurate
explanation any time that a post-mortem is required,
whether it is a coronial or non-coronial procedure.
In addition, Mori may wish to be present during the
procedure, and the tppaku should be released to the
family as quickly as possible afterwards. The removal or
cutting of any hair from the tppaku should be avoided
whenever possible;50 if it is necessary, an explanation should
be made ahead of time to the whnau. Any tissue, body
Case studies
CASE ONE:
Smoking Can Be Bad for Your Health
Recognition of complementary world views
A 62 year old Mori man who works in a bank visited his
Pkeh GP because he didnt feel well. As the consultation
progressed, the doctor felt that it was not going too well,
so he shared these thoughts with the patient and asked if
there was something else bothering him. The patient sighed
and said yes. He said, I know whats wrong, doc. I know
why Im crook. I took tobacco to the urup and then had a
smoke. The GP told the Mori patient that he didnt know
what the significance of that was and asked if he could
explain. The patient revealed that the urup is tapu, while
cigarettes are noa, so he had committed a serious breach.
The doctor asked the patient if he knew what he had to
do about that. The Mori patient heaved another sigh and
explained that he had to see a priest.
Without deriding the patients belief system (No, no.
The tobacco has nothing to do with it youve got heart
failure caused by a decreased cardiac ejection fraction
secondary to hypertension and atherosclerosis.), the doctor
acknowledged that while the patient sought assistance
for the violation of tapu within the Mori culture, he could
prescribe medicines to help with the breathlessness.
The patients firmly held belief as to why he is unwell
(disease attribution) is rooted in his cultural world view:
hes unwell because hes breached tapu by taking tobacco
into urup and then smoking it. It is generally non-productive
CASE TWO:
She Never Showed Up!
Practice bad manners
A Mori woman named Miriama Te Kani went to the after
hours service after cutting her hand while preparing dinner.
After signing in, she and her husband waited patiently to be
seen. After several minutes, a nurse came out and called for
MrsTickanee. Mrs Te Kani did not recognise this as the
nurses attempt to pronounce her name and assumed she was
calling a different patient. The nurse called a few times more,
then summoned a different patient. This happened several
more times over the next 90 minutes.
The nurse became frustrated at the thought of a patient leaving
and expressed her frustration to her colleagues. It was a bad
cut too! I dont know why she would leave. I get so angry when
people dont take proper care of themselves. You wonder why
she bothered to come in the first place!
Meanwhile, Mr and Mrs Te Kani were getting increasingly upset
themselves. Mrs Te Kanis hand hurt, and both she and her
husband had seen many people who had arrived after her, and
who looked much healthier, being called back to be seen by
the doctor. She thought about going and asking why she hadnt
been seen, but finally decided it wasnt worth it. The TeKanis
left and drove 60 minutes to the public hospital where her
cousin worked. Mrs Te Kani was seen within 10 minutes.
CASE THREE:
We Are Family
The whnau factor
A 47 year old Mori woman presented to her GP and was
diagnosed with diabetes. The GP, through her conversation
with the patient about ethnicity, realised that for this
woman, like many Mori, the whnau formed the basic unit
of her society, and thus it needed to be the basic unit for
medical intervention. The GP made sure that rather than
educating only the patient about the disease, she worked
with the family as well. It is unlikely that the patient would
change her diet unless her whnau was also brought
into the consultation, so the doctor sat down with several
members of the family and explained to everyone about
diabetes, the pancreas, insulin, glucose levels, finger prick
testing, pharmaceutical interventions, diet and exercise,
complications and preventing complications. Since the
patient was one of the familys main cooks, she would not
change her diet or have a refrigerator full of healthy salads
and diet food while cooking all night for the rest of her
family. It was also important for other family members,
such as her daughters-in-law who also did some cooking,
to understand how her diet needed tochange.
The GP also recognised that, with the incidence of diabetes
and obesity disproportionately high in the Mori population,
it was likely that other members of the whnau would
develop diabetes in the future. She knew that by educating
CASE FOUR:
Everyone Benefits
Practice benefit of collecting ethnicity data
A GP was taken aside by his office manager who said,
You know, now that the practice has started asking all
our patients to identify their ethnic background, weve
discovered that our proportion of Mori patients is much
higher than we thought. But they use our services at much
lower rates than expected we should discuss this at our
next practice meeting.
CASE FIVE:
Who Knew?
Patient benefit of collecting ethnicity data
CASE SIX:
If Only He Had Asked Earlier
Build a relationship with the community
A non-Mori GP, who lived and worked in a coastal area
renowned for excellent rock fishing, had built a solid
relationship with the local Mori over many years of practice
as the sole GP. Many of his patients were Mori from the
local iwi, and he would attend their community cultural and
sporting events as often as he could. The tangata whenua
held him as a valued person in their community.
On a rare Sunday free of commitments, the GP decided
to head down to the beach with his son to go rock fishing.
They got to the beach with all their equipment to find
that the track to the fishing spot had been barricaded.
Scrawled signs posted nearby stated: Fishing Prohibited
and RHUI. The GP, unwilling to cause a fuss, decided to
head home with his son. On his walk to the car he noticed
a group of Mori going through the barricade and down to
the fishing spot. The GP was very angry that he had been
turned away, with his son, while the local Mori had been
let through, especially as he felt he had connected with the
tangata whenua.
CASE SEVEN:
Such a Simple Solution
Importance of face-to-face interaction
Mr Huata was a 47 year old Mori man who had been
injured in a crash during his work as a heavy vehicle driver.
The health professionals involved in his care were finding it
hard to maintain a pleasant demeanour with him, because
he often seemed surly and uncooperative when they spoke
with him on the telephone. They raised the issue during a
team meeting, and a Mori staff member at ACC suggested
a face-to-face meeting with the patient and all those involved
in his case.
A meeting was arranged with Mr Huata, his employer, ACC
staff, the Pae Arahi from the ACC branch, and Mr Huatas
whnau. After a formal welcome and refreshments provided
by the whnau, everyone present introduced themselves
and Mr Huata voiced his concern that, not only had he never
CASE EIGHT:
Health of the Body, Health of the Mind
Culturally competent health care for better outcomes
The following vignettes are excerpted from Dr Plunketts
description of working with Mori patients in a culturally
competent fashion,53 as found on the Te Iho website
(www.teiho.org):
We had admitted a young Mori woman (whom I will call
Karena) to the acute ward, who was extremely unwell with a
very severe manic state. At that point we had no ICU so she
was treated in the Quiet Lounge and her whnau all stayed
with her to help with her care. It was her first episode of
psychiatric illness so it was important to get it as right as
we could, to prevent her being traumatised and so that she
and her whnau would have a better relationship with mental
health services in the future (as a manic state generally
means coping with ongoing episodes of a bipolar disorder).
Ive never looked after anyone so acutely unwell, and
Karena initially absorbed huge doses of anti-manic
medications with initially hardly any benefit or even sedative
effect. Her whnau organised themselves into a system of
shifts across the wider whnau, so that three people were
with her at any time, and if it had not been for their devoted
care Im sure she would have spent a lot of time in seclusion
(a simple, quiet, locked room with a bed on the floor). As it
was, they managed her somehow, even though she was
very chaotic with changeable moods and erratic impulsive
behaviour, for the few days until lithium, a mood stabilising
Summary
Manuhiri: visitors
Hap: sub-tribe
Iwi: tribe
Rhui: prohibition
Rangatiratanga: chieftainship, authority
References
1.
10.
2.
11.
3.
4.
12.
5.
13.
6.
14.
7.
15.
8.
9.
16.
17.
18.
25.
19.
20.
21.
26.
27.
28.
22.
23.
29.
30.
24.
31.
References continued...
32.
40.
41.
33.
34.
42.
43.
44.
35.
45.
46.
47.
36.
37.
48.
38.
39.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
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Updated October 2006